Interaction of ritonavir-boosted tipranavir with loperamide does not result in loperamide-associated neurologic side effects in healthy volunteers

Abstract

Loperamide (LOP) is a peripherally acting opioid receptor agonist used for the management of chronic diarrhea through the reduction of gut motility. The lack of central opioid effects is partly due to the efflux activity of the multidrug resistance transporter P-glycoprotein (P-gp) at the blood-brain barrier. The protease inhibitors are substrates for P-gp and have the potential to cause increased LOP levels in the brain. Because protease inhibitors, including tipranavir (TPV), are often associated with diarrhea, they are commonly used in combination with LOP. The level of respiratory depression, the level of pupil constriction, the pharmacokinetics, and the safety of LOP alone compared with those of LOP-ritonavir (RTV), LOP-TPV, and LOP-TPV-RTV were evaluated in a randomized, open-label, parallel-group study with 24 healthy human immunodeficiency virus type 1-negative adults. Respiratory depression was assessed by determination of the ventilatory response to carbon dioxide. Tipranavir-containing regimens (LOP-TPV and LOP-TPV-RTV) caused decreases in the area under the concentration-time curve from time zero to infinity for LOP (51% and 63% decreases, respectively) and its metabolite (72% and 77% decreases, respectively), whereas RTV caused increases in the levels of exposure of LOP (121% increase) and its metabolite (44% increase). In vitro and in vivo data suggest that TPV is a substrate for and an inducer of P-gp activity. The respiratory response to LOP in combination with TPV and/or RTV was not different from that to LOP alone. There was no evidence that LOP had opioid effects in the central nervous system, as measured indirectly by CO2 response curves and pupillary response in the presence of TPV and/or RTV.

FIG. 1.

Study design and timeline.

FIG. 2.

(a) Mean percent baseline ventilatory slope (±2 SEMs) for LOP alone (n = 20) compared with that for LOP-TPV-RTV treatment (n = 20); AUC_0-6 (±SEM) for the percent baseline V_E-p_ETCO₂ response slope profile was not statistically significantly different from that observed for LOP alone (633.0 ± 38.6 versus 622.4 ± 31.4 baseline slope · h; P = 0.84); (b) mean percent baseline ventilatory slope (±2 SEMs) for LOP alone (n = 10) compared with that for LOP-TPV treatment (n = 10); AUC_0-6 (±SEM) for the percent baseline V_E-p_ETCO₂ response slope profile was not statistically significantly different from that observed for LOP alone (633.6 ± 59.5 versus 623.6 ± 48.5 baseline slope · h; P = 0.84); (c) mean percent baseline ventilatory slope (±2 SEMs) for LOP alone (n = 10) compared with that for LOP-RTV treatment (n = 9); AUC_0-6 (±SEM) for the percent baseline V_E-p_ETCO₂ response slope profile was not statistically significantly different from that observed for LOP alone (687.8 ± 59.2 versus 621.2 ± 45.1 baseline slope · h; P = 0.21).

FIG. 2.

(a) Mean percent baseline ventilatory slope (±2 SEMs) for LOP alone (n = 20) compared with that for LOP-TPV-RTV treatment (n = 20); AUC_0-6 (±SEM) for the percent baseline V_E-p_ETCO₂ response slope profile was not statistically significantly different from that observed for LOP alone (633.0 ± 38.6 versus 622.4 ± 31.4 baseline slope · h; P = 0.84); (b) mean percent baseline ventilatory slope (±2 SEMs) for LOP alone (n = 10) compared with that for LOP-TPV treatment (n = 10); AUC_0-6 (±SEM) for the percent baseline V_E-p_ETCO₂ response slope profile was not statistically significantly different from that observed for LOP alone (633.6 ± 59.5 versus 623.6 ± 48.5 baseline slope · h; P = 0.84); (c) mean percent baseline ventilatory slope (±2 SEMs) for LOP alone (n = 10) compared with that for LOP-RTV treatment (n = 9); AUC_0-6 (±SEM) for the percent baseline V_E-p_ETCO₂ response slope profile was not statistically significantly different from that observed for LOP alone (687.8 ± 59.2 versus 621.2 ± 45.1 baseline slope · h; P = 0.21).

FIG. 3.

Geometric mean plasma loperamide concentrations alone (n = 24) and in the presence of RTV (n = 11), TPV (n = 12), and TPV-RTV (n = 24), demonstrating that RTV increases LOP concentrations during coadministration, while TPV and TPV-RTV decrease LOP concentrations during coadministration.